Medicare Advantage Part C Medical Care Plan Rights

This section describes your Part C medical plan rights including grievances, coverage decisions, exceptions and appeal processes. For more detailed information, refer to Chapter 9 of the Evidence of Coverage.

Your Part C Medical Care Plan Rights

You have certain rights concerning your medical care. Specifically, you have the right to request a coverage decision, make an appeal to deal with problems related to your benefits and coverage for medical services including problems related to payment, and file a grievance regarding quality of care or other issues.

How to make a complaint (file a grievance) about quality of care, waiting times, customer service, or other concerns

This section explains how to use the process for making complaints. The complaint process is only used for certain types of problems. This includes problems related to quality of care, waiting times, and the customer service you receive. The formal name for "making a complaint" is called "filing a grievance."

What types of items might lead to filing a grievance?

  • Unresolved issues with Member Service

  • Problems with one of our network providers

  • Disagreement with any of our policies or benefit design

  • Suspicion of fraud or abuse

  • Marketing or sales activities that you feel are inappropriate

Step 1: Contact us promptly—either by phone or in writing.

  • Usually, calling Member Service is the first step. If there is anything else you need to do, Member Service will let you know. You can call Member Service at 1-800-200-4255 (TTY: 1-800-522-1254), 8:00 a.m. to 8:00 p.m. ET as follows: from February 15 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday, and from October 1 through February 14, 8:00 a.m. to 8:00 p.m. ET, seven days a week.

  • If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you do this, it means that we will use our formal procedure for answering grievances. Here's how it works:

All written grievances must be submitted to us within 60 days of the event or incident that caused your complaint. Your written grievance must contain: your name, address and membership number; your signature, or that of an authorized representative, including the date on which it is signed; and a description of the specific event and the date on which it occurred.

Whether you call or write, the complaint must be made within 60 calendar days after you had the problem you want to complain about.

WRITE

Blue Cross Blue Shield of Massachusetts
Medicare Advantage Grievance Coordinator
P.O. Box 55007
Boston, MA 02205
FAX: 1-617-246-8506

When your complaint is about quality of care, you can make your complaint to the Quality Improvement Organization (QIO).

  • The Quality Improvement Organization is a group of practicing doctors and other health care experts paid by the Federal government to check and improve the care given to Medicare patients.

  • To find the name, address, and phone number of the Quality Improvement Organization for your state, look in Chapter 2, Section 4, of your Evidence of Coverage. If you make a complaint to this organization, we will work with them to resolve your complaint.

  • Or you can make your complaint to both at the same time. If you wish, you can make your complaint about quality of care to us and also to the Quality Improvement Organization.

You can also get help and information from Medicare

For more information and help in handling a problem, you can also contact Medicare. Here are two ways to get information directly from Medicare:

  • You can call 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. TTY users should call
    1-877-486-2048.

  • You can visit the Medicare website.

How do I appoint a representative to help with a claim and authorize them to act on my behalf?

If you want a friend, relative, your doctor or other provider, or other person to be your representative, you must complete this
PDF Medicare Advantage Appointment of Representative Form. The form must be signed by you and by the person who you would like to act on your behalf. You must give our plan a copy of the signed form.

Medicare Complaint Form

You are now able to submit feedback about your Medicare health plan or prescription drug plan directly to Medicare using the form below. The Centers for Medicare & Medicaid Services (CMS) values your feedback and will use it to continue to improve the quality of the Medicare program. If you have any other feedback or concerns, or if this is an urgent matter, please call
1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users can call 1-877-486-2048.